Severity assessment criteria of acute cholecystitis
Concept of severity grading of acute cholecystitis
Patients with acute cholecystitis may present with a
spectrum of disease stages ranging from a mild,
self-limited illness to a fulminant, potentially life-
threatening illness. In these Guidelines we classify the
severity of acute cholecystitis into the following three
categories: mild (grade I), moderate (grade II), and scores, such as Marshalls multiple organ dysfunction
severe (grade III). A category for the most severe
grade of acute cholecystitis is needed because this grade
requires intensive care and urgent treatment (operation
and/or drainage) to save the patients life. However, the
vast majority of patients present with less severe forms
of the disease. In these patients, the major practical
question regarding management is whether it is advis-
able to perform cholecystectomy at the time of presen-
tation in the acute phase or whether other strategies of
management should be chosen during the acute phase,
followed by an interval cholecystectomy. Therefore, to
guide the clinician, the severity grading includes a
moderate group based on criteria predicting when
conditions might be unfavorable for cholecystectomy in
the acute phase (level 2b-4).1318 Patients who fall nei-
ther into the severe nor the moderate group form the
majority of patients with this disease; their disease is
suitable for management by cholecystectomy in the
acute phase, if comorbidities are not a factor. Defini-
tions of the three grades are given below.
Mild (grade I) acute cholecystitis
Mild acute cholecystitis occurs in a patient in whom
there are no findings of organ dysfunction, and there is
mild disease in the gallbladder, allowing for cholecys-
tectomy to be performed as a safe and low-risk proce-
dure. These patients do not have a severity index that
meets the criteria for moderate (grade II) or severe
(grade III) acute cholecystitis.
Moderate (grade II) acute cholecystitis
In moderate acute cholecystitis, the degree of acute
inflammation is likely to be associated with increased
operative difficulty to perform a cholecystectomy (level
2b-4).1318
Severe (grade III) acute cholecystitis
Severe acute cholecystitis is associated with organ
dysfunction.
Criteria for the severity assessment of acute cholecystitis
Acute cholecystitis has a better outcome/prognosis than
acute cholangitis but requires prompt treatment if gan-
grenous cholecystitis, emphysematous cholecystitis, or
torsion of the gallbladder are present. The progression
of acute cholecystitis from the mild/moderate to the se-
vere form means the development of the multiple organ
dysfunction syndrome (MODS). Organ dysfunction
(MOD) score, and the sequential organ failure assess-
ment (SOFA) score, are sometimes used to evaluate
organ dysfunction in critically ill patients. The Guide-
lines classify the severity of acute cholecystitis into three
grades (Tables 35): severe (grade III): acute chole-
cystitis associated with organ dysfunction, moderate
(grade II): acute cholecystitis associated with difficulty
to perform cholecystectomy due to local inflammation,
and mild (grade I): acute cholecystitis which does not
meet the criteria of severe or moderate acute cho-
lecystitis (these patients have acute cholecystitis but no
Table 3. Criteria for mild (grade I) acute cholecystitis
Mild (grade I) acute cholecystitis does not meet the
criteria of severe (grade III) or moderate (grade II)
acute cholecystitis. Grade I can also be defined as acute
cholecystitis in a healthy patient with no organ dysfunction
and only mild inflammatory changes in the gallbladder,
making cholecystectomy a safe and low-risk operative
procedure.
Table 4. Criteria for moderate (grade II) acute cholecystitis
Moderate acute cholecystitis is accompanied by any one
of the following conditions:
1. Elevated WBC count (>18 000/mm3)
2. Palpable tender mass in the right upper abdominal
quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (biliary peritonitis,
pericholecystic abscess, hepatic abscess, gangrenous
cholecystitis, emphysematous cholecystitis)
a
Laparoscopic surgery in acute cholecystitis should be performed
within 96 h after the onset (level 2b-4)13,14,16
Table 5. Criteria for severe (grade III) acute cholecystitis
Severe acute cholecystitis is accompanied by dysfunctions
in any one of the following organs/systems
1. Cardiovascular dysfunction (hypotension requiring
treatment with dopamine 5 g/kg per min, or any dose
of dobutamine)
2. Neurological dysfunction (decreased level of
consciousness)
3. Respiratory dysfunction (PaO2/FiO2 ratio <300)
4. Renal dysfunction (oliguria, creatinine >2.0 mg/dl)
5. Hepatic dysfunction (PT-INR >1.5)
6. Hematological dysfunction (platelet count <100 000/mm3)